Recurring concern
Failure to carry out required neurological observations
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Request correctionFirst reported 28 Feb 2014•Latest report 12 Jun 2026
What this concern includes
Includes failures of the neurological-observation process, including dedicated planning, continuity, staff competence, performance, accuracy, recording and adherence to applicable guidance where these failures concern neurological observations.
Not included
- Excludes generic clinical or vital-sign observations that are not specifically neurological observations.
- Excludes generic training, staffing, documentation or monitoring deficiencies unless the report directly ties them to the neurological-observation process.
- Excludes failures of escalation or treatment that are not part of carrying out or interpreting required neurological observations.
- Excludes unrelated observation processes, including psychiatric, prisoner, postoperative or neonatal observations, unless neurological observations are explicitly involved.
- Reports
- 26
- Individual concerns
- 33
- Date range
- 2014–2026
- Stated actions
- 55
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to carry out neurological observations at the required frequency
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Remind staff to follow ABMU neurological observation guidelines and disseminate the guidance through nursing leadership and professional forums.
Stated by Swansea Bay University Local Health Board -
Action
Audit October AMU fall-patient documentation for compliance with neurological observation requirements and identify improvement and support needs.
Stated by Swansea Bay University Local Health Board
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Concerns raised2
Failure to complete required neurological or general observations
Failure to accurately record and calculate neurological or general observations
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to conduct scheduled neuro observations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Failure to carry out regular and timely neurological observations
Failure to follow hospital protocol for neurological observation frequency
Failure of nursing staff to carry out accurate neurological observations
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Deliver Trust-wide neurological-observation training for registered nurses, including competence testing.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
Insufficient post-fall neurological observations before discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Reinforce the head-injury and falls-management pathway through face-to-face staff training.
Stated by Sandwell and West Birmingham Hospitals NHS Trust -
Action
Issue an internal Patient Safety Notice on neurological observations and linking inpatient falls with head-injury management.
Stated by Sandwell and West Birmingham Hospitals NHS Trust -
Action
Amend the inpatient falls policy to require post-incident monitoring and link emergency-department and ward standards.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
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Action
Install the new electronic patient record to provide decision support and alerts reinforcing inpatient-falls and head-injury standards.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing head-injury and inpatient-falls policies meet NICE and NPSA standards and remain suitable for staff use.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
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Concerns raised2
Failure to ensure trained staff carry out neuro observations in line with policy
Failure of qualified nurse oversight to identify omitted neuro observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Assign responsibility for neurological observations to registered nurses only.
Stated by Cardiff & Vale University LHB -
Action
Review Health Care Support Workers’ clinical skills, including their role in neurological observations.
Stated by Cardiff & Vale University LHB
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Concerns raised1
Failure to conduct required neurological observations after falls
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to complete or retain neurological observation charts
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Reissue the neurological-observations flowchart and direct ward leaders to apply its recording requirements after relevant unwitnessed falls.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
There is no evidence that neurological observation charts were lost from the records; that inference would be conjecture.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to undertake nursing observations in accordance with required procedures and guidance
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Disseminate head-injury NICE guidance to ward sisters across the Medicine Clinical Board.
Stated by Cardiff & Vale University LHB -
Action
Audit known fallers with head injuries for compliance with NICE guidance and UHB falls-management policies.
Stated by Cardiff & Vale University LHB
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Concerns raised1
Failure to institute neurological observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Disseminate learning about vital information handover and neurological observations through meetings, safety huddles and the ED Quality Newsletter.
Stated by Stockport NHS Foundation Trust
Data last updated 7 September 2026